How To Get A Self Funded Ppo Plan From Foundation For Medical Care Of California

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1 Self-Insured Schools of California: Schools Helping Schools FOUNDATION SISC PPO PLAN Administered by Blue Shield of California 2014/2015 Enrollment Guide

2 Blue Shield of California is proud to be the benefit administrator of the SISC PPO plan. This plan is offered to school districts that are members of Self-Insured Schools of California (SISC). Blue Shield offers you access to large provider networks and a wide range of proven programs and services that help you get the most value from your plan. Powered by public school employees Self-Insured Schools of California (SISC) was established in We operate as a public school Joint Powers Authority (JPA) administered by the Kern County Superintendent of Schools Office. Our staff members are certificated and classified public school employees. Just like schools, SISC is subject to the Brown Act. We are a transparent operation. All board meetings are open to the public and our financial statements are a matter of public record. SISC is run in the best interests of our membership. We do not receive sales commissions. Our focus is on the value we provide to our members not a profit margin. Schools Helping Schools Joining together with other schools provides SISC members with the most stable long-term insurance solutions available. Our commitment to controlling costs is reflected in our mission of providing affordable rates and continued access to quality health care. Blue Shield of California, an independent member of the Blue Shield Association, is committed to care, not profit. Blue Shield has been part of California s healthcare landscape since 1939, and we remain passionate about not only improving the health and wellness of our members, but also giving back to the communities where we live and work. As a not-for-profit health plan, we re dedicated to providing Californians with access to high-quality health care at an affordable price. Blue Shield Mobile Apps You now have quick and easy access to benefits information anytime, anywhere with the new Blue Shield of California Mobile Apps. Download the app to your iphone or Android to view your ID card, review plan benefits, find providers, and more. Learn more by visiting blueshieldca.com/sisc.

3 We re here to help If you have any questions, simply contact your dedicated Foundation for Medical Care of Tulare and Kings Counties Customer Service team at (800) for personal assistance, from 7 a.m. to 7 p.m., Monday through Friday. Learn about the SISC PPO plan A self-funded plan administered by Blue Shield of California With the SISC PPO plan, you may select any physicians and hospitals within the plan s network, as well as outside of the network, for covered services. If maintaining a relationship with your current doctor is important to you, selecting the SISC PPO plan will give you the freedom to continue seeing your current doctor for most covered services, even if your doctor isn t part of the plan s provider network. Keep in mind that if your physician is not part of the plan s PPO network, you will have to pay more for each visit. Key features of the SISC PPO plan Network Non-network Choosing a doctor Visit any PPO network physician. Visit any non-network physician, pay for the services, and submit claims to Blue Shield. Access to specialists Visit any PPO network specialist; no referral is required. Visit any non-network specialist and submit claims to Blue Shield. No referral is required. Out-of-pocket costs After the plan-year deductible is met, pay a percentage of costs for covered services. After the plan-year deductible is met, pay a percentage of costs and all costs above the allowable amount. Urgent care If it s not an emergency, but you need care before your doctor can see you, or during hours when your doctor s office is closed, you should consider going to an urgent care center. You can keep your medical costs down by choosing a network urgent care center for non-emergency care, rather than going to the emergency room. You can locate an urgent care facility by going to the Find a Provider section of blueshieldca.com/sisc. Or call the Foundation for Medical Care of Tulare and Kings Counties Customer Service team at (800) blueshieldca.com/sisc 3

4 If you don t have access to the Internet or need help, simply contact your dedicated Foundation for Medical Care of Tulare and Kings Counties Customer Service team at (800) for personal assistance. Find a network provider Blue Shield s PPO network is one of the largest in California, with more than 70,000 physicians and 350 hospitals. It s easy to find a provider online Go to blueshieldca.com/sisc. Select Find a Provider. Under Find a PPO Network Provider, choose the provider you are looking for. Finding providers outside of California The BlueCard Program gives SISC PPO participants access to care across the United States and urgent care around the world. You are not required to use a BlueCard provider; however, it s in your best interest to use a BlueCard provider to keep your costs down. You can locate a BlueCard provider at any time by calling (800) 810-BLUE or by going to the Find a Provider section of blueshieldca.com/sisc. Find out your provider s quality of care rankings You can easily access quality scores, efficiency indicators, patient satisfaction scores, and cost information for many physicians and hospitals. To see a provider s performance profile, simply follow the steps above to find a provider and then click on the name of the doctor or hospital from your search results. 4 Blue Shield of California

5 Understand your pharmacy benefits Navitus Health Solutions pharmacy benefits Navitus Health Solutions* administers the pharmacy benefits for the SISC PPO plan and is committed to lowering drug costs, improving health, and delivering superior service. If you have any questions about your pharmacy benefits, just call the Navitus Health Solutions member services representatives at (866) They re available 24 hours a day, seven days a week to help you understand and manage medications used to treat a wide variety of conditions. Plan participants who take stabilized doses of covered long-term maintenance medications like those used to treat an ongoing condition such as high blood pressure or high cholesterol can save money by ordering them through the Navitus mail service partner, Costco pharmacy, instead of using a retail pharmacy. With mail service prescriptions: You get up to a 90-day supply delivered directly to you with free standard shipping. You can easily order refills online, over the phone, or by mail. Multiple safety and advanced quality checks are in place to make sure you get the right medication. Save money on generic prescriptions at Costco SISC has partnered with Costco to offer SISC PPO plan participants the option to fill a generic prescription at Costco for a $0 copayment for most plans. You do not need to be a Costco member to use the Costco pharmacy. Please note that some narcotic pain medications and cough medications are excluded. It s simple to fill generic prescriptions at Costco: 1. Take your prescription for a generic medication to a Costco pharmacy. 2. Present the pharmacist with your SISC PPO member ID card. * Navitus Health Solutions is independent from Blue Shield of California. blueshieldca.com/sisc 5

6 Discover more Helpful programs, services, and resources are available to you over the phone and online to help you and your family stay healthy. Prenatal Program This program gives expectant parents 24/7 access to experienced maternity nurses as well as prenatal information including a popular pregnancy or parenting book at no additional cost. Some materials are also available in Spanish. Plan participants can enroll by logging in to blueshieldca.com or calling (877) Preventive health guidelines Be sure to stay current with the screenings and tests appropriate to your age, gender, medical history, current health, and family history. You and your covered dependents have access to preventive exams and services defined as routine preventive care without having to pay a copayment as long as you seek care from a network provider. To download these guidelines, go to blueshieldca.com/sisc and select Preventive Health Guidelines from the home page. Condition management programs These programs offer nurse support as well as education and self-management tools for plan participants with certain chronic conditions, such as diabetes and coronary artery disease. Plan participants can apply to the programs by logging in to blueshieldca.com or calling (866) Surgery decision support Blue Shield of California is offering an additional resource to help you when a surgery may be in your future. Welvie, 1 an online surgery decision-support program, will answer your questions, help you make decisions, and guide you toward a positive outcome. With Welvie s help, you might decide to try a less invasive treatment. But if surgery is the decision, Welvie helps you understand what to expect from pre-op preparations to recovery. You and any covered family members can each receive a $25 amazon.com gift card when you complete Steps 1 through 3 of the program and a brief survey. To learn more about the program and how to complete the steps to earn rewards, visit blueshieldca.com/sisc, select Programs and Services and then Surgery Decision Support. The gift card offer is available once a year. Wellness discount program Blue Shield offers a variety of member discounts on popular programs 2 that can help you save money and get healthier. Weight Watchers Get discounts on three- and 12-month subscriptions, monthly passes, and at-home kits. 24 Hour Fitness Enjoy waived enrollment, processing, and initiation fees and discounts on monthly membership dues. ClubSport and Renaissance ClubSport Obtain a 60% discount on enrollments when joining with a month-to-month agreement. Enrollment fees are waived when joining with a 12-month agreement. (There is a one-time $25 processing fee when you enroll.) Alternative Care Discount Program Get 25% off usual and customary fees for acupuncture, massage therapy, and chiropractic services, plus get discounts on health and wellness products, with free shipping on most items. Discount Provider Network 3 Take 20% off the published retail prices when you use a participating provider in the Discount Vision Program network for exams, frames, lenses, and more. MESVision Optics Take advantage of competitive prices on contact lenses, 4 sunglasses, readers, and eyecare accessories, with free shipping on orders over $50. QualSight LASIK Save on LASIK surgery at more than 45 surgery centers in California. Services include prescreening, a preoperative exam, and postoperative visits. NVISION Laser Eye Centers Receive a 15% discount on LASIK surgery from experienced surgeons with offices in Southern California and Sacramento. 6 Blue Shield of California

7 Programs and services offered through SISC MDLIVE, the Employee Assistance Program, and Health Smarts are independent from Blue Shield of California. MDLIVE SISC offers MDLIVE as an optional service to SISC PPO plan participants. MDLIVE provides plan participants with access to doctors and pediatricians conveniently over the phone or via online video or secure . The cost is only $5.00 per consultation. Available 24/7, 365 days a year (including holidays), you can use MDLIVE to get answers to your questions when: You are considering ER or urgent care for non-emergency care You are traveling and need medical care Your primary doctor isn t available To begin using this service, you must first register by calling MDLIVE at (888) or by going to You will need to have your member ID number and the name, address, and phone number of the covered member who needs medical assistance. Health Smarts is SISC s health improvement program for members and their families. Through Health Smarts, you and your family have access to tools and resources that provide the incentives and support needed to keep you in good health. These include: Onsite biometric screenings* Onsite flu shot clinics* Condition management * If available in your district. Please note that this service may be discontinued without notice. Employee Assistance Program SISC offers an Employee Assistance Program (EAP) to plan participants. This program offers employees and retirees (excluding individual retiree plans) support to meet life s challenges, such as relationship difficulties, marriage/family situations, stress, managing change, legal and financial problems, work related concerns, anxiety and depression. This program can also help with issues that are more serious such as alcohol and drug problems, family violence and threats of suicide. You can access EAP services 24/7 toll free at (800) You can also find more information by visiting anthemeap.com. 1 Welvie is a limited liability company which offers its services to SISC plan participants and Blue Shield of California members. Welvie is an independent company and is not affiliated with Blue Shield or SISC. Neither Blue Shield nor SISC makes any recommendations, representations, claims, or guarantees regarding the Welvie services. 2 These discount program services are not a covered benefit of the SISC PPO plan, and none of the terms or conditions of the SISC PPO plan apply. The networks of practitioners and facilities in the discount programs are managed by the external program administrators identified below, including any screening and credentialing of providers. Blue Shield does not review the services provided by discount program providers for medical necessity or efficacy, nor does Blue Shield make any recommendations, representations, claims, or guarantees regarding the practitioners, their availability, fees, services, or products. Some services offered through the discount program may already be included as part of the SISC PPO plan covered benefits. Participants should access those covered services prior to using the discount program. Participants who are not satisfied with products or services received from the discount program may use the grievance process described in the Benefit Booklet. Blue Shield reserves the right to terminate this program at any time without notice. Discount programs administered by or arranged through the following independent companies: Alternative Care Discount Program American Specialty Health Systems, Inc. and American Specialty Health Networks, Inc. Discount Provider Network and MESVisionOptics.com MESVision Weight control Weight Watchers North America Fitness facilities 24 Hour Fitness, ClubSport, and Renaissance ClubSport LASIK Laser Eye Care of California, LLC; QualSight, Inc.; and NVISION Laser Eye Centers Note: No genetic information, including family medical history, is gathered, shared, or used from these programs. 3 The Discount Provider Network is available throughout California. Coverage in other states may be limited. Find participating providers by going to blueshieldca.com/fap. 4 Requires a prescription from your doctor or licensed optical professional. Blue Shield and the Shield symbol are registered marks of the BlueCross BlueShield Association, an association of independent Blue Cross and Blue Shield plans. blueshieldca.com/sisc 7

8 SISC (661) sisc.kern.org/hw Tips for new plan members Your new Blue Shield member ID card You will receive your new member ID in the mail before your plan s effective date. Only the name of the subscriber will be included on the card and not the names of covered dependents. After you receive your new member ID card, let your doctor or pharmacist know that you have changed health plans and present your new ID card to them. To verify your covered dependents, please call the Foundation for Medical Care of Tulare and Kings Counties Customer Service team. If you need an additional member ID card, you can print an ID card by going to blueshieldca.com/sisc and selecting Log in or Register for an account. After you log in, you can choose Print Temporary ID Card on the Plan Overview page. Transitioning prescription medications If you take prescription medications, you can help ensure a smooth transition to your new plan by having an adequate supply of your medications on hand. If you currently receive prescriptions through a mail-service pharmacy, you will need to have your prescribing physician issue a new prescription. You can then transfer your prescription to your new mail-service pharmacy. See page 5 for details on pharmacy benefits. Accessing care through network providers To maximize your plan benefits and minimize your out-of-pocket expenses, make sure to access covered services through Blue Shield network providers. To find out how to search for providers, see page 4 of this brochure. We re here to help Foundation for Medical Care of Tulare and Kings Counties Customer Service... (800) Blue Shield of California BlueCard Program...(800) 810-BLUE Prenatal Program...(877) Condition management programs... (866) Blue Shield of California Privacy Office... (888) Employee Assistance Program... (800) MDLIVE... (888) To learn more about your health benefits, and Blue Shield programs and services, and to find providers, go to blueshieldca.com/sisc. Blue Shield of California is an independent member of the Blue Shield Association A44289-SISC-PPO-FD (7/14)